Motor Vehicle Protective Device Usage Associated with Decreased Rate of Flail Chest: A Retrospective Database Analysis.

Background and Objectives: Protective equipment, including seatbelts and airbags, have dramatically reduced the morbidity and mortality rates associated with motor vehicle collisions (MVCs). While generally associated with a reduced rate of injury, the effect of motor vehicle protective equipment on patterns of chest wall trauma is unknown. We hypothesized that protective equipment would affect the rate of flail chest after an MVC. Materials and Methods: This study was a retrospective analysis of the 2019 iteration of the American College of Surgeons Trauma Quality Program (ACS-TQIP) database. Rib fracture types were categorized as non-flail chest rib fractures and flail chest using ICD-10 diagnosis coding. The primary outcome was the occurrence of flail chests after motor vehicle collisions. The protective equipment evaluated were seatbelts and airbags. We performed bivariate and multivariate logistic regression to determine the association of flail chest with the utilization of vehicle protective equipment. Results: We identified 25,101 patients with rib fractures after motor vehicle collisions. In bivariate analysis, the severity of the rib fractures was associated with seatbelt type, airbag status, smoking history, and history of cerebrovascular accident (CVA). In multivariate analysis, seatbelt use and airbag deployment (OR 0.76 CI 0.65-0.89) were independently associated with a decreased rate of flail chest. In an interaction analysis, flail chest was only reduced when a lap belt was used in combination with the deployed airbag (OR 0.59 CI 0.43-0.80) when a shoulder belt was used without airbag deployment (0.69 CI 0.49-0.97), or when a shoulder belt was used with airbag deployment (0.57 CI 0.46-0.70). Conclusions: Although motor vehicle protective equipment is associated with a decreased rate of flail chest after a motor vehicle collision, the benefit is only observed when lap belts and airbags are used simultaneously or when a shoulder belt is used. These data highlight the importance of occupant seatbelt compliance and suggest the effect of motor vehicle restraint systems in reducing severe chest wall injuries.

Impact of flail chest injury on morbidity and outcome: ten years' experience at a tertiary care hospital in a developing country.

BACKGROUND: One of the worst types of severe chest injuries seen by clinicians is flail chest. This study aims to measure the overall mortality rate among flail chest patients and then to correlate mortality with several demographic, pathologic, and management factors. METHODOLOGY: A retrospective observational study tracked a total of 376 flail chest patients admitted to the emergency intensive care unit (EICU) and surgical intensive care unit (SICU) at Zagazig University over 120 months. The main outcome measurement was overall mortality. The secondary outcomes were the association of age and sex, concomitant head injury, lung and cardiac contusions, the onset of mechanical ventilation (MV) and chest tubes insertion, the length of mechanical ventilation and ICU stay in days, injury severity score (ISS), associated surgeries, pneumonia, sepsis, the implication of standard fluid therapy and steroid therapy, and the systemic and regional analgesia, with the overall mortality rates. RESULTS: The mortality rate was 19.9% overall. The shorter onset of MV and chest tube insertion, and the longer ICU, and hospital length of stay were noted in the mortality group compared with the survived group (P-value less than 0.05). Concomitant head injuries, associated surgeries, pneumonia, pneumothorax, sepsis, lung and myocardial contusion, standard fluid therapy, and steroid therapy were significantly correlated with mortality (P-value less than 0.05). MV had no statistically significant effect on mortality. Regional analgesia (58.8%) had a significantly higher survival rate than intravenous fentanyl infusion (41.2%). In multivariate analysis, sepsis, concomitant head injury, and high ISS were independent predictors for mortality [OR (95% CI) = 568.98 (19.49-16613.52), 6.86 (2.86-16.49), and 1.19 (1.09-1.30), respectively]. CONCLUSION: The current report recorded mortality of 19.9% between flail chest injury patients. Sepsis, concomitant head injury, and higher ISS are the independent risk factors for mortality when associated with flail chest injury. Considering restricted fluid management strategy and regional analgesia may help better outcome for flail chest injury patients.

Long term outcomes following rib fracture fixation in patients with major chest trauma.

BACKGROUND: Severe chest injuries are associated with significant morbidity and mortality. Surgical rib fixation has become a more commonplace procedure to improve chest wall mechanics, pain, and function. The aim of this study was to characterise the epidemiology and long-term functional outcomes of chest trauma patients who underwent rib fixation in a major trauma centre (MTC). METHODOLOGY: This was a retrospective review (2014-19) of all adult patients with significant chest injury who had rib fixation surgery following blunt trauma to the chest. The primary outcome was functional recovery after hospital discharge, and secondary outcomes included length of intensive care unit (ICU) and hospital stay, maximum organ support, tracheostomy insertion, ventilator days. RESULTS: 60 patients underwent rib fixation. Patients were mainly male (82%) with median age 52 (range 24-83) years, injury severity score (ISS) of 29 (21-38), 10 (4-19) broken ribs, and flail segment in 90% of patients. Forty-six patients (77%) had a good outcome (GOSE grade 6-8). Patients in the poor outcome group (23%; GOSE 1-5) tended to be older [55 (39-83) years vs. 51 (24-78); p = 0.05] and had longer length of hospital stay [42 (19-82) days vs. 24 (7-90); p<0.01]. Injury severity, rate of mechanical ventilation or organ dysfunction did not affect long term outcome. Nineteen patients (32%) were not mechanically ventilated. CONCLUSIONS: Rib fixation was associated with good long-term outcomes in severely injured patients. Age was the only predictor of long-term outcome. The results suggest that rib fixation be considered in patients with severe chest injuries and may also benefit those who are not mechanically ventilated but are at risk of deterioration.

The significance of a concomitant clavicle fracture in flail chest patients: incidence, concomitant injuries, and outcome of 12,348 polytraumata from the TraumaRegister DGU®.

PURPOSE: Isolated clavicle fractures (CF) rarely show complications, but their influence in the thorax trauma of the seriously injured still remains unclear. Some authors associate CF with a higher degree of chest injuries; therefore, the clavicle is meant to be a gatekeeper of the thorax. METHODS: A retrospective analysis of the TraumaRegister DGU® (project 2017-10) was carried out involving the years 2009-2016 (ISS ≥ 16, primary admission to a trauma center). Cohort formation: unilateral and bilateral flail chest injuries (FC), respectively, with and without a concomitant CF. RESULTS: 73,141 patients (26.5% female) met the inclusion criteria and 12,348 had flail chest injuries (FC; 20.0% CF; 67.7% monolateral FC), 25,425 other rib fractures (17.7% CF), and 35,368 had no rib fractures (6.5% CF). On average, monolateral FC patients were 56.0 ± 17.9 years old and bilateral FC patients were 57.7 ± 19 years old. The ISS in unilateral and bilateral FC were 29.1 ± 11.7 and 42.2 ± 12.9 points, respectively. FC with a CF occurred more frequently with bicycle and motorbike injuries in monolateral FC and pedestrians in bilateral FC injuries and less frequently due to falls. Patients with a CF in addition to a FC had longer hospital and ICU stays, underwent artificially respiration for longer periods, and died less often than patients without a CF. The effects were highly significant in bilateral FC. CF indicates more relevant concomitant injuries of the lung, scapula, and spinal column. Moreover, CF was associated with more injuries of the extremities in monolateral CF. CONCLUSION: Due to the relevance of a concomitant CF fracture in FC, diagnostics should focus on finding CFs or rule them out. Combined costoclavicular injuries are associated with a significantly higher degree of thoracic injuries and longer hospital stays.

Multiple rib fractures: does flail chest matter?

BACKGROUND: Recent studies have reported significant morbidity and mortality in patients with multiple rib fractures, even without flail chest. The aim of this study was to compare the clinical outcome and incidence of associated chest injuries between patients with and without flail chest, with three or more rib fractures. METHODS: This study included patients with blunt trauma with at least three rib fractures, hospitalised during 2010-2019 in the Hillel Yaffe Medical Center in central Israel (level II trauma centre). Patients with and without radiologically defined flail chest were compared with regard to demographics, Injury Severity Score (ISS), GCS, systolic blood pressure (SBP) on admission, radiological evidence of flail chest, associated chest injuries, length of stay in intensive care unit, length of hospitalisation and mortality. RESULTS: The study included 407 patients, of which 79 (19.4%) had flail chest. Overall, pneumothorax and haemothorax were more common among patients with flail chest (p<0.05). When comparing patients with three to five rib fractures, there was no difference in length of intensive care and length of hospitalisation or mortality; however, there was a higher incidence of pneumothorax (24.6% vs 50.0%, p<0.05). When comparing patients with six or more rib fractures, no difference was found between patients with and without flail chest. CONCLUSION: In patients with three to five rib fractures, pneumothorax is more common among patients with flail chest. Clinical significance of flail chest in patients with more than six rib fractures is questionable and flail chest may not be a reliable marker for severity of chest injury in patients with more than six fractures.

Rib fixation in geriatric trauma: Mortality benefits for the most vulnerable patients.

BACKGROUND: Rib fractures in the geriatric trauma population are associated with significant morbidity and mortality. The outcomes of surgical stabilization of rib fractures (SSRF) have not been well defined in this population. METHODS: Data from the 2016 to 2017 Trauma Quality Improvement Program database were analyzed. Patients older than 65 years admitted with isolated chest wall injury and multiple rib fractures were abstracted from the database. Multivariate propensity score matching was utilized to stratify patients that underwent rib fixation versus nonoperative management. In the matched cohort, we assessed outcomes including mortality, intensive care unit (ICU) and hospital lengths of stay (LOS), tracheostomy rates, and ventilator-associated pneumonia (VAP) rates. We performed a secondary analysis of patients receiving early (<72 hours) versus late SSRF. RESULTS: Of the 44,450 patients included in the study analysis, 758 (1.7%) underwent SSRF. Patients undergoing SSRF were younger, had a higher prevalence of flail chest, higher rates of emergency room intubation, higher Injury Severity Score, and increased ICU admission rates. The 1:1 propensity score match resulted in 758 patients in each group. The in-hospital mortality rate was significantly lower in patients that underwent SSRF (4.2% vs. 7.3%, p = 0.01). However, the fixation group also had higher rates of tracheostomy during admission (11.2% vs. 4.6%, p < 0.001) and VAP (3.0% vs. 1.6%, p = 0.007). In a secondary matched analysis of 326 pairs of patients undergoing SSRF, we found that early fixation was associated with decreased rates of VAP (1.5% vs. 4.6%, p = 0.01), fewer ventilator days (4 days vs. 7 days, p = 0.003), shorter ICU LOS (6 days vs. 9 days, p = 0.001), and shorter hospital LOS (10 days vs. 15 days, p < 0.001). CONCLUSION: This study demonstrates a mortality benefit in geriatric trauma patients undergoing SSRF. Early SSRF was observed to be associated with decreased rates of VAP, decreased ICU LOS, and decreased hospital LOS. Early SSRF may be associated with improved outcomes in the geriatric trauma population with multiple rib fractures. LEVEL OF EVIDENCE: Therapeutic/Care management, level III.

Epidemiology of adult rib fracture and factors associated with surgical fixation: Analysis of a chest wall injury dataset from England and Wales.

INTRODUCTION: Chest wall trauma is commonly seen in patients admitted with both high and low-energy transfer injury. Whilst often associated with other injuries, it is also seen in isolation following simple falls in the older patient. Fixation of the chest wall grows in popularity as part of optimising patient care, particularly in terms of critical care stay. There is currently no description of the epidemiology of these injuries at a national level; nor has there been identification of factors that predict which of these patients undergoes surgery. METHODS: The United Kingdom Trauma Audit & Research Network (TARN) database was analysed for the period April 2016 to 30th May 2017 for all adult patients presenting with a rib or sternal fracture. Characteristics of the population were described and a binary logistic regression model constructed to explore the influences of several explanatory variables on whether fixation was performed. RESULTS: Of 16,638 patients with chest wall trauma, 402 underwent fixation. Most chest wall injury patients were admitted under three specialties (orthopaedics (19.1%), emergency medicine (16.6%) and general surgery (17.7%)). The odds of fixation in unilateral flail chest was 107.51 (p <0.0001), in bilateral flail or combined complexsternal fracture 47.63 (p = 0.007) and in 3 or more non-flail ribs 15.62 (p<0.0001) when compared to less than three non-flail rib fractures. The odds of fixation was higher in an MTC (p<0.0001) compared to a non-specialist hospital. The odds of fixation was higher in older patients (1.02, p<0.0001) and the more severely injured (1.02, p<0.0001). CONCLUSION: There is considerable variation nationally in the management of chest wall trauma. Injury type, patient age and care setting contribute to decision making in fracture fixation. This unique national dataset characterises for the first time the nature of contemporary chest wall trauma management and should help inform the design of future research on this topic.

The Respiratory Rate: A Neglected Triage Tool for Pre-hospital Identification of Trauma Patients.

BACKGROUND: Under-triaged trauma patients have worse clinical outcomes. We evaluated the capability of four pre-hospital variables to identify this population at the lowest level trauma activation (level 3). METHODS: A retrospective review of adult trauma activations from 2004 to 2014 was completed. Pre-hospital vital signs and Glasgow Coma Scale were converted to categorical variables. Patients were under-triaged based on meeting current level 1 or 2 criteria, or requiring a pre-defined critical intervention. Logistic regression was used to determine the association between the pre-hospital variables and under-triaged patients. Odds ratios and 95% confidence intervals were calculated for a comprehensive model, grouping all causes of under-triage as a single unit, and 16 individual models, one for each under-triage criterion. A new level 2 criterion was generated and internally validated. RESULTS: In total, 12,332 activations occurred during the study period. Four hundred and sixty-six (5.9%) patients were under-triaged. Compared to patients with a normal respiratory rate (RR), tachypneic patients were more likely to be under-triaged for any reason, OR 1.7 [1.3-2.1], p < 0.001. In the individual event analysis, tachypneic patients were more likely to have flail chest, OR 22 [2.9-168.3], p = 0.003; require a chest tube, OR 3 [1.8-4.9], p < 0.001; or require emergent intubation, OR 1.6 [1.1-2.8], p = 0.04, compared to patients with a normal RR. The data-driven triage modification was tachypnea with suspected thoracic injury which reduced the under-triage rate by 1.2%. CONCLUSION: Tachypnea with suspected thoracic injury is the strongest level 2 triage modification to reduce level 3 under-triage.

The natural history of flail chest injuries.

PURPOSE: Flail chest (FC) injuries represent a significant burden on trauma services because of its high morbidity and mortality. Current gold standard conservative management strategies for FC, are now being challenged by renewed interest in surgical rib fixation. This retrospective epidemiological study sets out to evaluate FC patients, and quantify the natural history of this injury by studying the injury patterns, epidemiology and mortality of patients sustaining FC injuries admitted to a major trauma centre (MTC). METHODS: A retrospective cohort analysis has been conducted at an MTC with full trauma service. All patients (age > 16 years) sustaining FC were included. Patient demographics, injury characteristics and inpatient stay information were extracted. RESULTS: Two hundred and ninety-three patients were identified, with a mean injury severity score (ISS) of 28.9 (range 9-75), average age of 56.1 years (range of 16-100), and a male predominance (78%). Road traffic accidents accounted for 45% (n = 132) of injuries, whilst 44% were fall or jump from height (n = 129). Associated lung contusion was present in 133 patients (45%) while 76% of patients were found to have 5 or more ribs involved in the flail segment (n = 223) with 96% (n = 281) having a unilateral FC. Inpatient treatment was required 19.9 days (range 0-150 days) with 59% of patients (n = 173) requiring intensive care unit (ICU) level care for 8.4 days (range 1-63) with 61.8% requiring mechanical ventilation (n = 107) for 10.5 days (range 1-54), and 7.8% underwent rib fixation with rib plates (n = 23). The mortality rate was found to be 14% (n = 42). A non-significant trend towards improved outcomes in the conservative group was found when compared with the fixation group; ventilation days (6.94 vs 10.06, p = 0.18) intensive treatment unit (ITU) length of stay (LOS) (12.56 vs 15.53, p = 0.28) and hospital LOS (32.62 vs 35.24, p = 0.69). CONCLUSION: This study has successfully described the natural history of flail chest injuries, and has found a nonsignificant trend towards better outcomes with conservative management. With the cohort and management challenges now defined, work on outcome improvement can be targeted. In addition the comparability of results to other studies makes collaboration with other MTCs a realistic proposal.

Concomitant Sternal Fracture in Flail Chest: An Analysis of 21,741 Polytrauma Patients from the TraumaRegister DGU®.

Background Isolated sternal fractures (SFs) rarely show complications, but their influence in a thorax trauma of the seriously injured still remains unclear. Methods A retrospective analysis of the TraumaRegister DGU® was performed involving the years 2009 to 2013 (Injury Severity Score [ISS] ≥ 16, primary admission to a trauma center). Cohort formation: Unilateral and bilateral flail chest (FC) injuries with and without a concomitant SF, respectively. Results In total, 21,741 patients (25% female) met the inclusion criteria, with 3,492 (16.1%) showing SF. Unilateral FC patients were on average 53.6 ± 18.4 years old, and bilateral FC patients were on average 55.2 ± 17.7 years old. The ISS in unilateral FC and bilateral FC amounted to 31.2 ± 13.0 and 43.4 ± 13.1 points, respectively. FC with an SF occurred more frequently as an injury to car occupants and less frequently as an injury to motorcyclists or in injuries due to falls. Conclusion Patients with an SF additional to an FC had longer hospital and intensive care unit stays and were longer artificially respirated than those patients without an SF. SF indicates possible cardiac and thoracic spine injuries.

Operative Treatment of Rib Fractures in Flail Chest Injuries: A Meta-analysis and Cost-Effectiveness Analysis.

OBJECTIVES: Flail chest is a common injury sustained by patients who experience high-energy blunt chest trauma and results in severe respiratory compromise because of altered mechanics of respiration. There has been increased interest in operative fixation of these injuries with the intention of restoring the mechanical integrity of the chest wall, and several studies have shown that ventilation requirements and pulmonary complications may be decreased with operative intervention. The purpose of this study was to evaluate fixation of rib fractures in flail chest injuries using cost-effectiveness analysis, supported by systematic review and meta-analysis. METHODS: This was a 2-part study in which we initially conducted a systematic literature review and meta-analysis on outcomes after operative fixation of flail chest injuries, evaluating intensive care unit (ICU) stay, hospital length of stay (LOS), mortality, pneumonia, and need for tracheostomy. The results were then applied to a decision-analysis model comparing the costs and outcomes of operative fixation versus nonoperative treatment. The validity of the results was tested using probabilistic sensitivity analysis. RESULTS: Operative treatment decreased mortality, pneumonia, and tracheotomy (risk ratios of 0.44, 0.59, and 0.52, respectively), as well as time in ICU and total LOS (3.3 and 4.8 days, respectively). Operative fixation was associated with higher costs than nonoperative treatment ($23,682 vs. $8629 per case, respectively) and superior outcomes (32.60 quality-adjusted life year (QALY) vs. 30.84 QALY), giving it an incremental cost-effectiveness ratio of $8577/QALY. CONCLUSIONS: Surgical fixation of rib fractures sustained from flail chest injuries decreased ICU time, mortality, pulmonary complications, and hospital LOS and resulted in improved health care-related outcomes and was a cost-effective intervention. These results were sensitive to overall complication rates, and operations should be conducted by surgeons or combined surgical teams comfortable with both thoracic anatomy and exposures as well as with the principles and techniques of internal fixation. LEVEL OF EVIDENCE: Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

In patients with acute flail chest does surgical rib fixation improve outcomes in terms of morbidity and mortality?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was: In patients with acute flail chest does surgical rib fixation improve outcomes in terms of morbidity and mortality? Using the reported search criteria, 137 papers were found. Of these, 11 papers (N = 1712) represent the best evidence to answer the clinical question, and include one meta-analysis, two randomized, controlled trials (RCTs), five retrospective cohort studies and two case-control series. In-hospital mortality was lower for the surgical group in the meta-analysis [n = 582, odds ratio (OR) 0.31 (0.20-0.48), risk difference (RD) 0.19 (0.13-0.26), number needed to treat (NNT) 5] as well as significant decreases in ventilator days [mean 8 days, 95% confidence interval (CI) 5-10 days] and intensive care unit stay (mean 5 days, 95% CI 2-8 days). A reduction was found for septicaemia [n = 345, OR 0.36 (0.19-0.71), RD 0.14 (0.56-0.23), NNT 7], pneumonia [n = 616, OR 0.18 (0.11-0.32), RD 0.31 (0.21-0.41), NNT 3, P = 0.001], tracheostomy (OR 0.06, 95% CI 0.02-0.20) and chest wall deformity [n = 228, OR 0.11 (0.02-0.60), RD 0.30 (0.00-0.60), NNT 3]. Eight studies (n = 1015) had a shorter duration of mechanical ventilation following surgery. A reduction in intensive care unit stay was demonstrated in four papers (n = 389, 3.1-9.0 days), whereas a further three papers described a reduction in the duration of hospitalization (n = 489, 4-10.6 days). Three studies (n = 166) showed a lower risk for tracheostomy. One retrospective cohort study estimated lower total treatment costs in surgically treated patients ($32 300 vs $37 100) although not statistically significant. One retrospective case-control study described a lower risk for reintubation (n = 50, P = 0.034) and home oxygen requirements (n = 50, P = 0.034). One cohort study showed a better APACHE II score 14 days after trauma in the surgical group (P = 0.02). Surgical stabilization of flail chest in thoracic trauma patients has beneficial effects with respect to reduced ventilatory support, shorter intensive care and hospital stay, reduced incidence of pneumonia and septicaemia, decreased risk of chest deformity and an overall reduced mortality when compared with patients who received non-operative management.

Severe blunt thoracic trauma: differences between adults and children in a level I trauma centre.

BACKGROUND: Trauma is a leading cause of death in the developing world. Blunt thoracic trauma represents a major burden of disease in both adults and children. Few studies have investigated the differences between these two patient groups. OBJECTIVE: To compare mechanism of injury, presentation, management and outcome in children and adults with blunt thoracic trauma. METHODS: Patients were identified from the database of the trauma intensive care unit at Inkosi Albert Luthuli Central Hospital, Durban, South Africa. Demographics and relevant data were extracted from a pre-existing database. RESULTS: Of 415 patients admitted to the unit, 331 (79.7%) were adults and 84 (20.2%) children aged < 18 years. The median injury severity score (ISS) was similar for both age groups (32 v. 34; p = 0.812). Adults had a higher lactate level at presentation (3.94 v. 2.60 mmol/L; p = 0.001). Of the children, 96.4% were injured in motor vehicle collisions, 75.0% as pedestrians. Compared with adults, children had significantly fewer rib fractures (20.2% v. 42.0%; p < 0.001), flail chests (2.4% v. 26.3%; p<0.001) and.blunt cardiac injuries (BCIs) (9.5% v. 23.6%; p = 0.004), but sustained more lung contusions (79.8% v. 65.6%; p = 0.013). Mortality in children was significantly lower than in adults (16.7% v. 27.8%; p = 0.037). CONCLUSION: Thoracic injuries in children are the result of pedestrian collisions more often than in adults. They suffer fewer rib fractures and BCIs, but more lung contusions. Despite similar ISSs, children have significantly lower mortality than adults. More effort needs to be concentrated on child safety and preventing pedestrian injury.

The rising burden of serious thoracic trauma sustained by motorcyclists in road traffic crashes.

In many countries increased on-road motorcycling participation has contributed to increased motorcyclist morbidity and mortality over recent decades. Improved helmet technologies and increased helmet wearing rates have contributed to reductions in serious head injuries, to the point where in many regions thoracic injury is now the most frequently occurring serious injury. However, few advances have been made in reducing the severity of motorcyclist thoracic injury. The aim of the present study is to provide needed information regarding serious motorcyclist thoracic trauma, to assist motorcycling groups, road safety advocates and road authorities develop and prioritise counter-measures and ultimately reduce the rising trauma burden. For this purpose, a data collection of linked police-reported and hospital data was established, and considerable attention was given to establishing a weighting procedure to estimate hospital cases not reported to police and fatal cases not admitted to hospital. The resulting data collection of an estimated 19,979 hospitalised motorcyclists is used to provide detailed information on the nature, incidence and risk factors for thoracic trauma. Over the last decade the incidence of motorcyclist serious thoracic injury has more than doubled in the population considered, and by 2011 while motorcycles comprised 3.2% of the registered vehicle fleet, one quarter of road traffic-related serious thoracic trauma cases treated in hospitals were motorcyclists. Motor-vehicle collisions, fixed object collisions and non-collision crashes were fairly evenly represented amongst these cases, while older motorcyclists were over-represented. Several prevention strategies are identified and discussed.

Thoracic trauma in Iraq and Afghanistan.

BACKGROUND: Thoracic injuries are common among civilian trauma and have a high associated mortality. The use of body armor and exposure to different mechanisms of injury in combat setting could lead to different injury patterns and incidences from those found in peacetime. METHODS: Thoracic trauma incidence rates and mortality risks were calculated from data extracted from the Joint Theatre Trauma Registry. RESULTS: Among patients injured in military operations in Iraq and Afghanistan, 10.0% sustained thoracic injuries and had a mortality rate of 10.5%. Penetrating injuries were the most common mechanism of injury. The most common thoracic injury was pulmonary contusion. The highest mortality rate was in the subset of patients with thoracic vascular injuries or flail chest. The variables most strongly associated with mortality were number of units of blood transfused, admission base deficit, international normalization ratio, pH, Abbreviated Injury Scale scores for head and neck regions, and Injury Severity Score. Blunt injuries had the same mortality risk as penetrating injuries. CONCLUSION: Combat-related thoracic trauma is common and associated with significant mortality in Iraq and Afghanistan.

Factors affecting morbidity and mortality in flail chest: comparison of anterior and lateral location.

OBJECTIVE: Flail chest is most often accompanied by significant underlying pulmonary parenchymal injuries and may constitute a life-threatening thoracic injury. In this study we evaluated the treatment modalities for flail chest depending on the effect of trauma localization on mortality and morbidity. METHODS: Between 2003 and 2008, 23 patients (20 males/3 females) were treated for flail chest. Location of the trauma in the chest wall, mechanical ventilation support, prognosis and injury severity score (ISS) were recorded for all patients. Mechanical ventilation support was given in 14 patients (60.8 %), and 12 of these 14 patients required subsequent tracheostomy. Internal fixation was used in 3 patients. RESULTS: The major cause of flail chest was a car crash in 18 of 23 patients (76 %). Median ISS was 62.8 for all patients. The patients with flail chest who had bilateral costochondral separation (anterior chest location) (group I, n = 10) had a significantly higher ISS than those with single-side posterolateral flail chest (group II, n = 13; ISS: 70/55; P = 0.02). The need for mechanical ventilation support was also higher in the group with bilateral costochondral separation. Morbidity was higher in group I than in group II ( P = 0.198), and mortality was also significantly higher in group I ( P = 0.08). Patients with a cranial trauma and flail chest had a higher mortality (19 %) than patients with only flail chest (no mortality). The mean ISS was 75 for patients with cranial trauma and flail chest and 55.7 ( P = 0.001) for patients with only flail chest. Sepsis and subarachnoid bleeding were the major causes of mortality. The mean ISS was 54.5 for patients under the age of 55 (n = 14) whereas it was 69.4 in those aged 55 and over (n = 9; P = 0.034). Mortality in the older group was also higher (33 % versus 7 %; P = 0.02). CONCLUSION: Early intubation and mechanical ventilation is of paramount importance in patients with flail chest. However, prolonged mechanical ventilation is associated with a poor outcome. Tracheotomy and frequent flexible bronchoscopy are an effective pulmonary toilet. Advanced age was a major risk factor for flail chest trauma mortality, together with the severity of the injury. When cranial trauma was accompanied by flail chest, mortality and morbidity rates increased. Bilateral costochondral separation also increased the risk of morbidity and the need for mechanical ventilation in patients with flail chest.

[Flail chest due to blunt trauma: clinical features and factors affecting prognosis]. / Künt travmaya bagli yelken gögüs: Klinik özellikler ve prognozu etkileyen faktörler.

BACKGROUND: We evaluated the clinical features of patients with flail chest, together with treatment results, and the factors affecting prognosis. METHODS: The study included 34 patients (27 males, 7 females; mean age 41 years; range 15-61 years) who underwent treatment for flail chest. A retrospective analysis was made regarding the etiology, injury to the chest wall, pulmonary contusion, hemothorax and pneumothorax requiring chest tube, associated injuries, injury severity score (ISS), the presence of shock on admission, the amount of blood transfusions within the first 24 hours, treatment, and the results. RESULTS: The most common cause of flail chest was traffic accidents (79.4%). Shock was detected in 41.2% and pulmonary contusions in 55.9%. Ventilatory support was required in 70.6%. The mean ISS was 36; mortality occurred in 32.4%. In seven patients without associated injuries and who did not receive ventilatory support, the mean ISS was 22.8 and all survived. However, in 18 patients with associated organ injuries, the mean ISS was 43.6, with mortality being 50% (p<0.05). Factors responsible for prolonged ventilatory support, pneumonia, and septic deaths included ISS above 31, associated fractures and injuries, blood transfusions, the need for chest tube, age equal to or above 50 years, and the presence of bilateral flail chest. The incidences of pneumonia and mortality were significantly less in patients treated with internal fixation (p<0.05). CONCLUSION: Our data show that careful fluid management and effective pain control, stabilization of the chest wall, immediate ventilatory support and early weaning from ventilation are the mainstays of treatment.

Multiplane transesophageal echocardiography performed according to the guidelines of the American Society of Echocardiography in patients with mitral valve prolapse, flail, and endocarditis: diagnostic accuracy in the identification of mitral regurgitant defects by correlation with surgical findings.

Multiplane transesophageal echocardiography is a useful tool to study mitral regurgitation. We evaluated the diagnostic accuracy of multiplane transesophageal echocardiography performed according to the guidelines of the American Society of Echocardiography. We used 4 midesophageal and 2 transgastric views in 313 patients with degenerative lesions, endocarditic lesions, or both to identify regurgitant defects, comparing transesophageal echocardiography results with surgical findings. The overall diagnostic accuracy using individual scallops was 97.2% (P <.00001) with a sensitivity of 96.6% and a specificity of 97.6%. Considering the single sections of the mitral valve, an accuracy of 98%, 97.1%, and 98%, was found, respectively, for the lateral, middle, and medial third of the anterior leaflet. For the posterior leaflet, the accuracy was 98% for the lateral scallop, 98.4% for the middle, and 96.1% for the medial. This strategy provides good accuracy in diagnosing both simple and challenging mitral-valve lesions and its widespread use should be recommended.

Clinical management of flail chest in dogs and cats: a retrospective study of 24 cases (1989-1999).

Cases of flail chest injury for 24 client-owned companion animals following various traumas were evaluated. Concurrently sustained injuries, initial emergency treatments, and definitive treatment and outcome for regimens that utilize stabilization of the flail segment were compared with cases treated with no stabilization. Flail chest was confirmed in 24 animals: 21 dogs and three cats. There was an even division (12 each) of right and left flail segments. The median number of ribs involved was three (range, two to seven). Flail segment stabilization was performed in nine, and 15 were treated with no stabilization. Statistical analysis using multiple data permutations evaluating all combinations failed to reveal a significant difference in outcome between stabilized and unstabilized cases.

[Rib fractures and flail chest in closed chest trauma--stabilizing operations and the results]. / Rebreni frakturi i grudni kapatsi pri zakrita grudna travma--stabilizirashti operatsii i rezultati.

A contingent of patients presenting closed chest injuries, sustained over a 12-year period (1985-1996), are analyzed. Of the total of 6938 traumas, chest injuries amount to 3286 (47.06 per cent) of which 2842 (40.7 per cent)-closed. Of the latter 2248 (79.09 per cent) are located in the left thoracic half, 420 (14.77 per cent)-in the right thoracic half, and in 174 (6.12 per cent) it is a matter of bilateral involvement. At the point of heaviest impact, involving 5th to 9th rib segment, left side injury is recorded in 2034 cases (71.56 per cent), right side--408 (14.35 per cent), and bilateral--in 155 (5.45 per cent). There are 28 fractures of the sternum (0.85 per cent). Of the latter 14 are located in the manubrium sterni region, twelve--in the middle portion, and two in the distal part of the sternum. Over the last 5 years (1991 through 1995), of 63 casualties with flail chest 16 are with indications for stabilization osteosynthesis, and accordingly subjected to operation. A Schimelmann plate is used in 13 cases, artificial rib type "Ampar"--in three, and sternal stabilization--in one.